Form 5309 - Application For Determination Of Employee Stock Ownership Plan Page 2
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Form 5309 (Rev. 1-2012)
Page
Yes No
Does the plan provide that a participant may begin receiving a distribution of his or her account that is attributable
j
to employer securities after the participant has separated from service upon reaching normal retirement age, or after
death, disability, or other separation from service, within the time frames specified in section 409(o)?
If the plan is maintained by a C corporation, does the plan provide that the assets of the plan attributable to (or
k
allocable in lieu of) employer securities acquired by the plan in a sale to which section 1042 applies cannot accrue
(or be allocated directly or indirectly under any section 401(a) plan of the employer) for the benefit of persons
specified in section 409(n) during the nonallocation period?
Plans Applying Under Section 4975(d)(3) and Regulations Section 54.4975-7 (Leveraged ESOPs) (Complete lines 5a through 5g.)
Does the plan provide that the exempt loan proceeds must be used within a reasonable time to acquire qualifying
5a
employer securities, repay such loan, or repay a prior loan as required under Regulations section 54.4975-7(b)(4)?
Does the plan provide for the establishment and maintenance of a suspense account as required under Regulations
b
section 54.4975-11(c)?
Does the plan provide that the collateral must be limited to qualifying employer securities purchased with such
c
exempt loan or qualifying employer securities used as collateral on a prior exempt loan repaid with the proceeds of
the current exempt loan as required under Regulations section 54.4975-7(b)(5)?
Does the plan provide that no person entitled to payment under an exempt loan shall have any right to assets of the
d
ESOP other than collateral given for such loan, contributions (other than contributions of employer securities) made
to repay such exempt loan, and earnings attributable to such collateral and the investment of such contributions as
required under Regulations section 54.4975-7(b)(5)?
Does the plan provide that payments made with respect to an exempt loan by the ESOP during the year must not
e
exceed an amount equal to the sum of contributions and earnings received during or prior to such year less such
payments in prior years as required under Regulations section 54.4975-7(b)(5)?
Do plan terms provide that qualifying employer securities will be forfeited only after other assets as required under
f
Regulations section 54.4975-11(d)(4)?
Does the plan provide that the protections and rights provided to participants and beneficiaries with respect to
g
employer securities are nonterminable as required in Regulations section 54.4975-11(a)(3)(i) and (ii)?
Under penalties of perjury, I declare that I have examined this application, including accompanying statements and schedules, and to the best of my
knowledge and belief, it is true, correct, and complete.
Date
SIGN HERE
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Type or print title
5309
Form
(Rev. 1-2012)
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